Jennifer Nery, LAc -- Health history form
Please fill out this form online and click 'submit' at the end. It should take you 15 minutes or less to complete. Your information will be securely sent and securely saved in a file only viewable by your acupuncturist at CLINIC Alternative Medicines.

If you would prefer, a paper version will be available at the office before your appointment; please come 15 minutes early for your first appointment to fill it out if you prefer this.

Thanks very much, and we are looking forward to working with you!

Patient contact information
Last name *
Your answer
First name *
Your answer
Date of birth *
MM/DD/YYYY
Your answer
Street address *
Your answer
City *
Your answer
State *
Your answer
Zip code *
Your answer
Best phone number to reach you? *
Your answer
Would you like me to text message you at this number? *
Your answer
Email address
No junk, no sharing. Used for direct contact and less-than monthly updates from the practice.
Your answer
Facebook name
If you'd like to 'like' me there.
Your answer
Emergency contact name and relationship
Your answer
Emergency contact phone number
Your answer
Health concerns, problems, or goals
Below, please list your top health concerns. This may be a problem that has been bothering you, something that you're concerned about even if you're not having a lot of symptoms, or even a goal, like supporting good health. Feel free to include physical, mental, and emotional concerns you might have.
Concern #1 *
Your answer
Date of onset *
Enter "ongoing" for non-specific concerns or goals. Approximate for problems with an unknown onset. Enter "recurring" for problems you've had previously that have returned.
Your answer
Severity of symptoms *
No symptoms
Excruciating
How bothersome is this concern? *
How much does this concern interfere with your life and happiness?
Doesn't interfere at all
It bothers me all the time
Concern #2
Your answer
Date of onset
Enter "ongoing" for non-specific concerns or goals. Approximate for problems with an unknown onset. Enter "recurring" for problems you've had previously that have returned.
Your answer
Severity of symptoms
No symptoms
Excruciating
How bothersome is this concern?
How much does this concern interfere with your life and happiness?
Doesn't interfere at all
It bothers me all the time
Concern #3
Your answer
Date of onset
Enter "ongoing" for non-specific concerns or goals. Approximate for problems with an unknown onset. Enter "recurring" for problems you've had previously that have returned.
Your answer
Severity of symptoms
No symptoms
Excruciating
How bothersome is this concern?
How much does this concern interfere with your life and happiness?
Doesn't interfere at all
It bothers me all the time
Any concerns or questions about your health you've been wanting to ask or discuss?
Your answer
What services are you interested in receiving? *
Not just today, but ever.
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